Medical Power of Attorney (Healthcare Proxy) 

Parties 

• Principal: [Full Name], residing at [Address], hereinafter referred to as the “Principal.” 

• Healthcare Agent: [Full Name], residing at [Address], hereinafter referred to as the “Agent.” 

Grant of Authority 

The principal hereby designates the Agent to make healthcare decisions for the principal if the principal is unable to make or communicate such decisions. This includes the authority to: 

• Consent to, refuse, or withdraw consent for medical treatment, surgery, or diagnostic procedures. 

• Employ or discharge healthcare personnel. 

• Access and disclose medical records, subject to HIPAA and relevant privacy laws. 

• Make end-of-life decisions, including the use or withdrawal of life-sustaining measures, consistent with the principal’s known wishes or best interests. 

  
  

Effective Date 

This Medical Power of Attorney becomes effective only when the principal’s primary physician or another qualified medical professional determines that the principal is unable to make or communicate informed medical decisions. 

Durability 

This Medical Power of Attorney is durable and shall not be affected by the Principal’s incapacity, except as stated herein or by operation of law. 

Agent’s Duties 

• The Agent must make decisions in line with the Principal’s known wishes, religious beliefs, or moral values. 

• If the Principal’s preferences are unknown, the Agent must act in the Principal’s best interests. 

• The Agent must keep records of the medical decisions made on behalf of the Principal. 

Revocation 

The Principal may revoke this Medical Power of Attorney at any time, orally or in writing, as permitted by law. 

HIPAA Waiver (If Applicable) 

“I intend for my Agent to be treated as my personal representative for HIPAA and other applicable medical privacy regulations. My Agent may access any and all of my medical information necessary to make informed healthcare decisions.” 

Governing Law 

This Medical Power of Attorney is governed by the laws of the State of [State]. 

Signatures and Acknowledgment 

Principal’s Signature: _________________________   Date: ______________ 

Printed Name: ________________________________ 

Agent’s Signature (if required by state law): ______________________   Date: __________ 

Printed Name: ________________________________ 

(Notarization or Witness Requirements Here)